Beom Koo Lee, M.D.

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Operation of Arthritic Knee- HTO vs UKA -

• Beom Koo Lee, M.D.
• Dept. of Orthopaedic Surgery
• Gil Medical Center, Gachon University

2

Surgical Options for Mono-compartmental OA

• Arthroscopic Debridedment
• Cartilage Transplantation
• Osteotomy
• UKA
• TKA

3
Discussion Point to compare HTO vs UKA

• Trend
• Survival
• Function
• Kinematics
• Indication contraindication
• Biologic aspect
• Perioperative morbidity
• Weight bearing, Rehabilitation, General
  Complication
• Problem
• Complication
• Cosmetics
• Technical Problem associated with TKA after
  Procedure

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Trend
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Trend of UKA

• The early reported series of unicompartmental
  knee replacement done by experienced surgeons did
  not have encouraging results, with 70
  survivorship reported at 5 to 7 years, and 65
  and 53 survivorships reported at 11 and 12
  years, respectively.
• Callahan, CORR, 2005

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Trend of UKA, Recently

• However, more recently the reports of
  unicompartmental knee replacement have been more
  encouraging with 94 survivorship at 10 years and
  90 survivorship at 18 years.
• Callahan, CORR, 2005

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Kinematics of UKA

• The UKA preserve Normal Kinematics
• Patil, JBJS(Am), 2005

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Kinematics of UKA

• Patil, JBJS(Am), 2005

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Kinematics of UKA

• Patil, JBJS(Am), 2005

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Kinematic of UKA

• Variable Femoral Roll Back
• Dennis, JBJS(Am), 2001

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Indications Contraindications
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Ideal Indications of HTO

• Young
• Active
• Male
• Varus Deformity
• Mont, AAOS ICL, 2004

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Ideal Indications of UKA

• Low Demand
• Female
• Elderly
• No instability Contracture
• Correctable Deformity
• Mont, AAOS ICL, 2004

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Contraindications
HTO UKA
Severe Deformity (?)
ACL Insufficiency -
P-F Arthritis
Obesity
Inflammatory Arthritis
Advanced Age -
Arthritis Opposite
Severe Contracture
Medial Plateau Depression -
Lateral Instability
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Range of Correction

• UKA
• Varus 10 - 20
• Valgus lt 15
• Preferably 10 Pagnano, AAOS ICL, 2005
• osteotomy
• Even Severe Deformity over 20 can be corrected by
  Dual Osteotomy.
• Hanssen Insall 3rd edit

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T-F angle Varus 14 Mechanical Axis Varus 20
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Lateral Instability

• moderate to severe Lateral instability, and
  subluxation is contraindicated in HTO
• (Insall 3rd edit)
• TKA is advisable in Great subluxation than UKA
• ( Insall 3rd edit)
• UKA is contraindicated for instability
  (ICL 2005)
• Management in Mild Lateral Laxity in HTO
• Slight Overcorrection
• Reefing of LCL ???
• Spontaneous shortening ???

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ACL Instability in UKA

• ACL insufficiency
• relative contraindication in UKA
• ICL 2005
• HTO can be done in ACL Deficiency
• Noyes, Am J Sports Med, 2000

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UKA in Elderly

• ORourke, CORR, 2005

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Summary of Indications

• UKA? HTO??? ??? Deformity ??? ?????, Ligament?
  Stable ????.
• UKA?? 80? ??? ????, 40?? ???? ????.
• HTO? ??? ?? ?? ??? ????.

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Survival
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Survival of UKA

• ORourke, CORR, 2005

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Survival of UKA

• Stukenborg, The Knee, 2001

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Survival of MIS-UKA

• Despite an accelerated recovery and decreased
  hospital stay in our MIS-UKA, the rate of
  Revision due to aseptic loosening and the overall
  Reoperation rate compare to unfavorably with
  those performed with an open technique.
• Engh, J Arthroplasty, 2006

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Survival of HTO

• Insall Scott, Surger of the Knee, 4th ed.

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Survival of HTO UKA
HTO
UKA

• ???, ????????, 2001

???, ?????????, 2002
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Summary of Survival

• ???? HTO? UKA? ??? ????.
• ?? ????? UKA? ??? ??? ????.

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Quality of Life
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Results of HTO vs UKA
UKA Results were signinficantly Better than HTO

• Broughton, JBJS(Br), 1986

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Function of HTO vs UKA
Better Function in HTO

• Stukenborg, The Knee, 2001

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Pain of HTO vs UKA

• Broughton, JBJS(Br), 1986

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Activity Level of HTO vs UKA

• Gillquist, CORR, 1991

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Activity after HTO

• Manual Labor 17/34
• Jumping Sport 45-60
• Nagel, JBJS(Am), 1996
• Odenbring, Acta Ortho Scan, 1989

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ROM

• HTO is better than UKA
• Koshino, APKS, 2006

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Kneeling

• HTO is better than UKA
• Koshino, APKS, 2006

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Summary of Quality of Life

• UKA?? ??? ???,
• ??? HTO?? ????.
• HTO?? ROM? ? ??, Kneeling? ?? ??.

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Biologic Aspect
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Cartilage Healing after HTO

• Joint Space
• Preop. 1.8mm
• 3 Yr F-up 2.9mm
• ???, ????????, 2002
• Joint Space (2Y F/U)
• Koshino
• -Joint space pre-op 1.1mm
• post-op 2.3mm
• -Pattern
• No reg13/146
• pink and yellow fibrillation 2/143
• Partial coverage 50/143
• Full coverrage 16/143
• 13,86,47/146

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Pre-op Medial joint space narrowing
Post-op 14 M Restored medial joint space
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Cartilage defect in tibia
Cartilage defect in femur
Pre-op
Regenerated cartilage
Healed cartilage
Post-op
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Healed cartilage defect site
POD 17 Months
initial
microfracture
post-op 2 Yr
POD 17 M
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Complications
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early perioperative complication after HTO vs
UKA

• Broughton, JBJS(Br), 1986

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Early Cx after HTO

• Infection
• Patella baja
• Intraarticular fracture
• Peroneal nerve dysfunction
• Compartment syndrome
• Vascular injury

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DVT Case after HTO

• Incidence 41
• Tuner, JBJS(Br), 1993

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Retained Cement after UKA
Engh, J Arthroplasty, 2006
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Rehabilitation

• Easy in UKA
• Faster Recovery
• Gillquist, CORR, 1991

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Summary of early perioperative course

• UKA? HTO??? Rehabilitation? ??,, Peri- operative
  Complication ??? ????.

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Cosmesis
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Alignment

• HTO Overcorrection
• UKA Undercorrection

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Tibia Vara with Mild OA

• Subcondylar Osteotomy with Blade Plate

Preop.
POD5Y
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• Tibio-Femoral Angle 13
• Defective Cosmesis
• Unbalance compared to
• Contralateral Side

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Staged Operation in Bilateral Case

• UKA One Stage
• HTO Two Stage

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Weight Bearing

• UKA Immediate
• HTO Delay 2-3 M

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Summary of Short Term Results

• UKA? HTO??? Weight Bearing, Cosmesis, ??? ????.

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Long tern complication
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Long term Cx after HTO

• Loss of correction
• Arthritis opposite compartment
• Decreased function over time.
• pseudoarthrosis

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Collapse after UKA

• Engh, J Arthroplasty, 2006

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Wear after UKA
Vince, J Arthroplasty, 2004
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Dislocation after UKA
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Fracture after UKA
Vince, J Arthroplasty, 2004
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Technical Problems Results of Revision
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Technical Problems of TKA after HTO (ICL 2004)

• Difficult Exposure
• Bone Defect
• Difficult Ligament Balance
• Prolonged Operative Time
• Increased Blood Loss
• Offset Stem Sometimes
• But, No Problem after Open Wedge HTO
• (Kitson) Injury 200132

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Frequent Encountered Problems at Revision

• UKA Bone Defect
• HTO Difficult Exposure
• Gillquist, CORR, 1991

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Results of TKA after HTOcompared with primary
TKA

• Less Successful
• (windsor 1988 JBJS)
  (Cameroon1996 orthopedic
• (Katz 1987 JBJS)
• More infection (Jackson J arthroplasty 1994)
• difficult exposure , mild decreased flexion but
• No difference
• (Haddad 2000 J arthroplasty)
• (Windsor)

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Summary of Problems at Revision

• HTO? Approach? ???? ??, UKA? Bone Defect? ????
  ??.
• ??? HTO? UKA ? Revision?? ??.

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Can We expand Indication of UKA in Young
Patients?

• We may rightfully expect Higher Failure Rates,
  perhaps Greater Damage in the Younger, More
  Active Patient. New, expanded Indications for UKA
  may lead to More Complications and perhaps More
  Severe Failures.
• Vince, J Arthroplasty, 2004

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Summary
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UKA

• Faster Recovery
• Immediate Weight Bearing
• High Initial Success Rate
• Fewer Early Complications
• Simultaneous Bilateral Procedure
• Better Cosmesis
• Less Infection
• Less Blood Loss
• Less Function and Activity
• 80? ??? ???? ?? ?? ??? ?? ? ??.
• Callahan, CORR, 2005
• Gillquist, CORR, 1991
• Insall

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HTO

• More Active Life Style
• Biologic
• Better Result at Revision than UKA
• ?? ??? ??.
• Weight Bearing
• Perioperative Complication
• Staging Procedure
• Morbidity
• Iorio, JBJS(Am), 2003
• Gill, CORR, 1995
• Chang

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J arthroplasty Oct06
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Future of UKA

• Although the unicompartmental prosthesis used in
  this series has not shown promising results and
  does not match the results of some other
  prosthesis, and the introduction of guide
  instruments for precise surgical techniques has
  currently improved the survival of UKAs to over
  90 at 10 years. Therefore, we think that in
  patients over 60 years of age, unicompartmental
  osteoarthritis UKA offers Better Long-term
  Results than HTO.
• Stukenborg, The Knee, 2001

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Future of HTO

• It is proposed that Future Biologic Resurfacing,
  together with Computer- and even Robotic-Methods,
  as well as other advances in Biology and
  Technology, will combine to resurrect the
  performance of knee osteotomies
• Krackow, J Arthroplasty, 2004

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Summary

• HTO? UKA? ? ??? ? ?? ??? ?? ? ??.
• Indication, Cosmesis, Function, Biologic??? ???
  ?? ????.
• HTO? ??? ??? ??, UKA? ??? ??? ??.
• HTO? ?? ??? ?? ??? ????.
• UKA? ??? ?? ????, 80? ???? ?? ??? ?? ? ??.
• ?? Biologic Procedure? ???? ? ?? HTO? ??? ???.

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Thank you for your attention